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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL+ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 01 <br /> 2 ik L!/ �> PM <br /> City Lot Size <br /> j Job Address <br /> 1 <br /> Address Phone <br /> Owner's Name I <br /> I! ; , 6 <br /> Contractor's Name <br /> License No. / Phone <br /> V6 -2607 <br /> "TYPE OF WELL/PUMP: � 1 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 13 OTHER-C7—T" "« <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- <br /> - <br /> ELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC710N SPECIFICATIONS Dia. of Well Casing <br /> El Industrial ❑ Open Bottom fa Manteca Dia. of Well Excavation ' <br /> Specifications <br /> T e of'Casing <br /> ❑ Domestic/Private <br /> ❑ Gravel Pack ED Tracy YP,�- , <br />++ ❑ Delta Depth of Grout Seal + Type of Grout <br /> ❑ Public 1-1 Other <br /> 13 Irrigation ---Approx. Depth El Eastern Surface Seal Installed by <br /> ' U <br /> Repair Work Done [I Type of Pump H.P. <br /> a_ State Work Done n <br /> ~Searin Material (top 50'1 r� U <br /> Well Destruction ❑ Well'Diameter 9 <br /> Depth t Filler Material"'(Below 501 <br /> } =TYPE OF SEPTIC WORK: NEW INSTALLATION D WPAIR"!•ADD'DIITION ~DESTRUCTION ❑ aNailable( o se �withsysm 200 feetltted if public sewer is <br /> Installation will serve: Residence— Commercial— (Other - . . . ,­­- r <br /> Ir <br /> Number of living units: 'i Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 1-1 :'g Method of Disposal <br /> Distance to nearest: Well Foundation Property Line''�`' � <br /> f LEACHING LINE LlNo. & Length of lines f • Total length/size <br /> FILTER BED ❑ Distance to nearest: ,Well E Foundation Property Line <br /> / I <br /> r 9 Number <br /> SEEPAGE PITS Depth 2` Size <br /> 1 �� Pro e 4 Li. y <br /> r SUMPS � ❑ Distance to nearest: ,We{I /1/nfll�- Foundation P rtY j { <br /> DISPOSAL PONDS Cl <br /> i hat the work will be done in accordance with San Joagyin county ordinances, state laws, and <br /> I hereby certify that 1 have prepared this application and t <br /> G rules and regulations of the San Joaquin Local Health District. t <br /> Homo owner or licensed agent's signature certifies the following: "I certify that in the performance of the work.for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation Iaws of California.'Contractor's hiring-or sub=contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this perm((is issued,�l shall employ persons subject t fkman's compensa <br /> tion laws of California." +!The applicant must call fo ali' q 'red ins tions. Complete drawing on re arse side.;,.'" . <br /> Signed <br /> . Title: Date: <br /> } "s <br /> FOR DEPARTM NT USE ONLY <br /> !Date Area <br /> Application Accepted by <br /> ). f ��` k• <br /> reit or Grout Inspection by ..r <br /> Date ' Final Inspection by ' Date <br /> - ,�"Additional Comments: P Lt ):�� —:7�rG <br /> Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 Tracy 835- <br /> pplicant- Return all copies o�to: Environmental Health Permit/Services 1601 E."Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> II <br /> FEE CK RECEIVED BY DATE PERMIT"NO. <br /> INFO AMOUNT DUE MOUNT REMITTED CASH <br /> + EH 13.24 IREV.101831 T V • �� �� <br /> EH W28 �.y c, i <br />